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Transitional Care Services: A Rising Referral Option to Reduce Readmissions

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On October 1, 2012, Medicare's Hospital Readmissions Reduction Program went into effect, intended to give hospitals financial incentive to ensure patients receive proper discharge instructions and post-discharge support.

The intensely debated Medicare penalties for excessive readmissions have put doctors, discharge nurses and other healthcare professionals across the hospital industry in a difficult position. How can you and your colleagues minimize the number of returning patients without extra funding for any necessary interventions?

As many hospitals have found, cooperation with community resources is key.

Hospitals in Syracuse, New York, for example, have taken measures to coordinate follow-up appointments with the patient's primary care doctor, transportation for patients to attend follow-up appointments, a meeting between a pharmacist and patient to eliminate confusion about medications, and home visits from nurses, according to

Many of these interventions to improve care transitions can be taken care of by local transitional care service providers at no extra cost to hospitals.

The Home Instead® network's Returning HomeSM transitional care services program is one referral option for discharge planners and patients.

Returning Home transitional care services include:

  • Discharge coordination and execution – working with a senior patient's hospital staff to help create a plan of care.
  • Medication management – assistance organizing and tracking medications to make sure they're taken as directed.
  • Follow-up physician visit assistance – helping seniors keep track of and attend all necessary follow-up medical appointments.
  • Nutrition management –providing assistance with food shopping and meal preparation to help ensure the senior maintains a healthy diet.
  • Warning sign monitoring and notification – watching for warning signs and taking appropriate action.
  • Record keeping – keeping track of the senior's recovery progress to share with his or her physicians.

While not all patient readmission cases are preventable, approximately $12 billion in Medicare costs for readmitted patients is believed to be avoidable, according to the Medicare Payment Advisory Commission.

By partnering with transitional care resources within the community, hospitals can address the cases where additional one-on-one home support can help increase the likelihood a patient makes a successful recovery without a return trip to the hospital.

For more information about readmission reduction and transitional care services, visit


Last revised: December 17, 2012

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